Laughing and crying, you know it's the same release. Joni Mitchell

Laughing and crying, you know it's the same release. Joni Mitchell

Wednesday, April 13, 2011

Fibromyalgia Symposium Part II: Mood Disturbance and FM

Dr. Sandhu speaks with symposium attendees
After a break and a light lunch, two of Dr. Don Goldenberg's colleagues presented information about the management of fibromyalgia. Dr. Sandhu spoke about mood disturbances and their treatment with regards to FM, and Dr. Boileau presented non-pharmacologic interventions. Then Dr. Goldenberg wrapped it up with an overview of the best management options. Although audience members filled out index cards with questions for the panel, there was no time for questions and answers - a real missed opportunity, although Drs. Boileau and Sandhu stayed afterward to speak with attendees.

Overlap of Fibromyalgia and Mood Disturbances and the Role of Mental Health Professionals: presented by Dr. Hartej Sandu, MD, Psychiatrist

The relationship between chronic pain and depression is common. In fact, 50% of people with chronic pain of any kind are also depressed; 80% of those with depression present with physical symptoms. There is a much greater prevalence of depression in all chronic illnesses, but especially in pain conditions like FM. The more severe the pain, the more severe the depression. 30% - 50% of FM patients experience depression and anxiety. In fact, the odds rate of mood disturbances are two times higher in FM patients compared to rheumatoid arthritis.

Dr. Sandu emphasized that fibromyalgia is a real condition, as are mood disturbances. The two conditions interact in a way that makes it more complex for both the patients and the medical providers. He presented three theories on the relationship and treatment of chronic pain and mood disturbances:

No. 1: Depression and stress are a by-product of chronic pain. Treatment is part of somatic (physical) medicine.

No. 2: Somatic symptoms are a manifestation of depression and anxiety. Treatment is primarily a psychiatric problem.

No. 3: Somatic and psychological symptoms are related but different reactions to the same stimulus such as genetic, physiologic and environmental factors. Treatment lies in the overlap of psychiatric and somatic medicine, which is where fibromyalgia lies. (Am I depressed because I'm sick or am I depressed as part of my sickness? My experience has been that the depression is physical, i.e. due to sudden drops in serotonin levels, rather than situational or psychological.)

Dr. Sandhu presented the link between depression and pain in the processes of the brain. Sensory pain is felt in the somata sensory areas which are located on the outermost parts of the brain (that's where my brain tumor was located and thus caused pain on my right side). In addition, affective (emotional) pain is processed in several inner parts of the brain, such as the amigdala, the lymbic system (hypocampus is the memory portion of the lymbic system) and the hypothalmus (controls the autonomic nervous system). All of these areas "light up" when people are stimulated with pain, which shows that there are clearly both sensory and emotional/affective components to pain. These two areas affect one another to complete the clinical picture. However, treating depression doesn't affect the sensory areas that light up in the brain.

Neurotransmitters such as serotonin and norepinephrine are the links to dealing with depression, espcially regarding drugs such as the SSRI's, SNRI's. Also, both neurotransmitters are crucial in the descending pain inhibitory pathway, which makes them key chemicals in dealing with both depression and fibromyalgia pain. 

Shared Features of FM and Depression:
  • strong genetic predisposition
  • serotonin transporter gene 5-HTT
  • sleep disturbances
  • cognitive disturbances
  • history of childhood abuse or stress
  • catastrophizing - the tendency to have a negative approach when anticipating the future which leads to a state of perceived helplessness. (I have to admit I can be guilty of this!) This has real significance in compounding the difficulties in both conditions. Treating depression does not decrease pain, but reducing catastrophizing does!
Studies show that patients with major depression have increased activity in the affective pain centers of the brain similar to that of fibromyalgia. Also, anticipation of pain or a sense of helplessness (catastrophising) causes the same stimulation in the affective regions of the brain. In major depression, patients have less of a capacity to regulate and decrease sensory pain.

Subgroups of FM Patients:

Group 1: Psychological Factors Neutral
  • low depression and anxiety
  • not very tender
  • low catastrophizing
  • moderate control over pain

Group 2: Psychological Factors Worsening Symptoms
  • high depression and anxiety
  • tender
  • very high catastrophizing
  • no control over pain

Group 3: Psychological Factors Improving Symptoms
  • low depression and anxiety
  • extremely tender
  • very low catastrophizing
  • high control over pain

It's fruitless to figure out what came first because mood disorders and pain work in unison. The symptoms are real and debilitating. Health care professionals need to work out a treatment approach to address the entire package in a wholistic fashion. Mental health providers should be part of the FM treatment team.


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